Clinical History

Imaging Findings

A 34-year-old man with dyspepsia, regurgitation, dysphagia, feeling of foreign body, chest pain and upper abdominal indisposition came to our hospital to undergo a digital fluoroscopic examination of the upper GI tract. The examination showed gastro-oesophageal reflux with signs of oesophagitis and hiatal hernia. Further, we noticed an ovoid mural lesion (2 cm) with clear margins along the greater curvature of the gastric antrum suggestive of a leiomyoma. EGDS confirmed the presence of hiatal hernia, oesophagitis and a gastric antral lesion. Biopsies were taken from the lesion; it showed inflammatory cells in superficial gastric mucosa with proliferation of uniform spindle shaped cells well differentiated and without mitotic figures. Moreover, US-endoscopy confirmed the diagnosis of leiomyoma but resection was not performed.

Discussion

Gastric leiomyoma (GLM) is a submucosal lesion; it originates from muscularis mucosa or muscularis propria, can be intraluminal or extramural and represents 2.5% of gastric neoplasms. Usually it is asymptomatic and is found at autopsy or during abdominal surgical exploration for other reasons. Incidental leiomyomas are not rare in resected specimens (3.5%). Clinical presentation depends on size, location, and type of development (endo- or exogastric tumours). Symptomatic GLM present with upper gastrointestinal bleeding, atypical epigastric pain or non-specific dyspepsia. Major symptoms are dysphagia, feeling of foreign body, pain behind chest bone, and upper abdominal indisposition. Bleeding is generally produced by mucosal ulceration and is the most common complication in all forms, but intraperitoneal haemorrhage is unusual.Most of the GLM are located in the body and fundus, rarely in the antrum.Diagnosis can only be suspected using radiological methods (double contrast X-ray, EUS, CT) but cannot be reached without a histological examination.On upper gastrointestinal tract contrast examination, GLM appear as rounded or ovoid swellings up to 15 cm in diameter, mainly in the submucosal region, occasionally with subserous extension. Not infrequently, ulcerations are present on the surface like a “niche.” The mucosal folds around the filling defect are moved apart but not disorganised. Endoscopy can suggest a benign submucosal lesion but cannot differentiate a GLM. EUS shows a homogeneous and hypoechoic lesion with a clear margin; it is the best method to characterise small GLM. Transabdominal US and CT will bring additional information in exogastric tumoral forms. Macroscopically, GLM is generally small, solitary, smooth, rounded, and more or less well circumscribed, but not encapsulated. Mucosa overlaying the tumour may be ulcerated, while peritumoral mucosa is normal. Microscopically, GLM presents as crossed bundles of large fusiform smooth muscle cells with eosinophilic cytoplasm, no myofibrillae, and scarce mitotic activity, which defines its benign character.Gastric leiomyomectomy is the standard treatment, the lesions not being radiosensitive. The advances in laparoscopic surgery have made it possible to convert open laparotomy to a minimally invasive procedure with obvious benefits for the patients. Laparoscopic wedge resection of GLM is technically feasible, safe, and useful.